Do Pancreatitis & cancer pancreas Cause Shoulder Pain?

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Patients with acute pancreatitis may experience left shoulder pain. This type of pain is more common in patients with local complications of acute pancreatitis such as hemorrhage, collections, massive pancreatic necrosis, and damage to the nearby spleen.

In patients with pancreatic cancer, left shoulder pain is even less common. And it is often due to malignant spread to the cervical vertebrae or left shoulder bones.

1. What are the early warning signs of pancreatitis?

Your pancreas is a small organ in the upper left quadrant of your abdomen. It lies behind the spleen and the stomach.

The pancreas’s main function is to release digestive enzymes that digest different food components (protein, fat, and carbohydrate). It also helps regulate blood sugar (mainly through insulin secretion).

The inflammation of the pancreas can be either:

  • Acute pancreatitis: sudden onset, severe, persistent pancreatic pain.
  • Chronic pancreatitis: prolonged mild or recurrent inflammation may lead to the destruction of the pancreatic tissue and loss of its function.

Early warning symptoms and signs of pancreatitis:

  • Sudden onset severe persistent pain in the upper central part of the abdomen (epigastric area.
  • The pain often radiates to the upper back. In complicated cases, the pain may also radiate to the left shoulder.
  • Sudden onset nausea.
  • Sudden onset vomiting.
  • Bloating and anorexia.
  • In gallstone pancreatitis (a stone’s obstruction of the pancreatic and biliary duct), jaundice, dark urine, and clay stool may develop.

2. How common is shoulder pain with pancreatitis?

There is no data assessing the frequency of shoulder pain in patients with acute pancreatitis. However, shoulder pain appears when there is a severe/complicated form of the disease.

Shoulder pain occurs only when the phrenic nerve supplying the left diaphragm becomes irritated. And this often doesn’t occur unless pancreatitis becomes complicated.

Complications that are more likely to cause left shoulder pain with pancreatitis include (reference):

  • Peripancreatic inflammatory collections.
  • Hemorrhagic pancreatitis.
  • Splenic affecting (abscess, splenic vein thrombosis, infarction) due to the spread of destructive digestive enzymes from the pancreas (Kehr’s sign).
  • Large pancreatic pseudocyst.
  • Walled-off pancreatic necrosis.

So, left shoulder pain in patients with acute pancreatitis may indicate severe pancreatitis. In addition, your doctor may need to re-assess the complications if the shoulder pain appears with pancreatitis.

3. Where is pancreatitis pain felt? And why does it affects the left shoulder?

Typically, pancreatic pain starts as sudden, severe, persistent pain in the upper central abdomen (epigastric area). Typically, the pain is confined to the epigastric area and radiates to the mid-back in 50% of the cases (reference).

Also, the pain commonly spreads to the upper left stomach area (the left hypochondrium). The pain often doesn’t come and go, but it may become partially relieved by sitting up or leaning forward.

Painless Pancreatitis!

Surprisingly, 5 to 10% of patients with severe acute pancreatitis may have painless diseases. Painless pancreatitis often occurs in critically ill patients, patients on dialysis, and patients with recent surgery (in the postoperative period).

In some cases, pancreatic pain may be felt in the left shoulder. This often occurs in complicated cases (hemorrhage, collections, or destruction of the surrounding organs due to pancreatitis).

It is unclear of the cases of painless pancreatitis can present with left shoulder pain without stomach pain or not.

Why pancreatitis causes left shoulder pain:

The local damage of tissues often irritates the left phrenic nerve (the nerve supplying the diaphragm). The phrenic nerve roots arise from the part of the vertebral column in the neck (cervical nerve roots C3, C4).

Another nerve group (the supraclavicular nerves) shares the same nerve roots with the phrenic nerve. These supraclavicular nerves are responsible for the pain sensation in the left shoulder.

So, irritation of the phrenic nerve may give rise to pain in the left shoulder due to the shared origin of these nerves (a classic example of referred pain).

The video below illustrates the idea of refereed pain:

4. How will your doctor diagnose pancreatitis?

The most famous diagnostic test of pancreatitis is testing for pancreatic enzymes (serum lipase and amylase).

However, these tests are not 100% specific and may be elevated in conditions such as perforated bowels, salivary gland diseases, etc.

So, if your doctor suspects pancreatitis based on your symptoms (severe stomach pain and left shoulder pain), he will often diagnose pancreatitis based on TWO out of THREE of the following:

  1. Pain is typical pancreatic pain (sudden, severe, persistent epigastric pain that spreads to the left upper abdomen and the mid-back).

  2. Lipase or amylaseserum levels of amylase or lipase greater than three times the upper limit of normal (ULN).

  3. Imaging: the presence of features suggestive of acute pancreatitis in abdominal imaging (ultrasound, contrast-enhanced CT, or MRI).

5. Who is at higher risk of pancreatitis?

  • Patients with gallstone disease40-70% of the cases of acute pancreatitis are due to slipped small gallstones obstructing the pancreatic duct.
  • Alcohol: Alcohol is responsible for 25-35% of the cases of acute pancreatitis in the United States.
  • Hypertriglyceridemia: increased blood lipids (triglycerides). Hypertriglyceridemia can be either primary (genetic) or secondary to diseases (such as diabetes, obesity, hypothyroidism, etc.).
  • Recent medical procedures such as ERCP (endoscopic retrograde cholangiopancreatography).
  • Genetic risks.
  • Medications.
  • Trauma to the pancreas.
  • Hypercalcemia (increased blood calcium): often due to a hyperactive parathyroid gland.
  • Some infections.

6. Does pancreatic cancer cause shoulder pain?

The most common symptoms of pancreatic cancer are pain, jaundice, and weight loss.

Unlike acute pancreatitis, the pain is often milder, more prolonged (for months), gnawing, and generally in the epigastric area.

It can spread to the upper left and upper right abdomen and back.

In some cases, pancreatic cancer can also spread to the left shoulder. However, shoulder pain with pancreatitis is rare and not specific to the disease.

Rarely, some cases may present with shoulder pain as an early sign of pancreatic cancer.

Most cases of shoulder pain due to pancreatic may be due to bone metastasis in the cervical vertebra or shoulder bones.

7. Other causes of referred pain to the left shoulder.

  • Spleen:
    Many spleen diseases may cause upper left stomach pain and left shoulder pain. Commonly, splenic rupture, splenic infarction, abscess, tumors, and infections.

  • The heart:
    Heart attack (acute coronary syndrome or myocardial ischemia) commonly spreads to the jaw, left shoulder, and the left arm. Also, pericarditis (inflammation of the thin membrane enveloping the heart) causes left shoulder pain.

  • The lungs and the pleura:
    Diseases affecting the left lung and pleura may irritate the diaphragm (phrenic nerve) and cause left shoulder pain.

  • Abdominal trauma causes injury to the internal organs and/or internal bleeding.

  • Ruptured ectopic pregnancy or ovarian cyst.

  • IBD (inflammatory bowel disease).

  • Complicated appendicitis or cholecystitis (with rupture or collection inside the peritoneum).

  • Perforated bowels or stomach.

8. What are the most common causes of shoulder pain?

  • Osteoarthritis.
  • Broken bones.
  • Shoulder dislocation.
  • Tears in the tendons of the shoulder joint.
  • Muscle strain.
  • Thoracic outlet syndrome (left-sided).
  • Paget’s disease.